Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’S Health Links

Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’s Health Links

Applied Health Research Question Series Volume 4.3

Health System Performance Research Network Report Prepared by: Dr. Seija Kromm, Luke Mondor, Dr. Walter P Wodchis

January 2015

Acknowledgements

The Health System Performance Research Network (HSPRN) is a multi-university and multi-institutional network of researchers who work closely with policy and provider decision makers to find ways to better manage the health system. The HSPRN receives funding from the Ontario Ministry of Health and Long-

Term Care (MOHLTC). The views expressed here are those of the authors with no endorsement from the

MOHLTC. We thank the MOHLTC Transformation Secretariat and the HSPRN Research Team for their support and suggestions. Particular thanks go to Goncalo Santos for assistance preparing this report, and

Peter Gozdyra for all geographic information system assistance.

Competing Interests: The authors declare that they have no competing interests.

Reproduction of this document for non-commercial purposes is permitted provided appropriate credit is given.

Cite as: Kromm S, Mondor L, Wodchis WP. Assessing Value in Ontario Health Links. Part 3: Measures of System Performance in Ontario’s Health Links. Applied Health Research Question Series. Volume 4.

Toronto: Health System Performance Research Network; 2015.

This report is available at the Health System Performance Research Network Website: http://hsprn.ca.

For inquiries, comments, and corrections please email [email protected].

Executive Summary

Context

Ontario’s Health Links (HL) initiative was launched in January 2013 to improve the coordination of care provided to patients with the most complex healthcare needs. This group of patients represents a small minority of the Ontario population (5%), but accounts for a majority of health system costs (66%). Health Links are a novel method of delivering integrated health care services to Ontarians. They are geographically defined, and each Health Link is given the flexibility to identify its target population and improve integration of care for complex, high-needs patients. Given the considerable efforts that are being invested in HLs, reporting on the system performance of HLs is an important priority.

Objective This report responds to an Applied Health Research Question (AHRQ) from the Ontario Ministry of Health and Long-Term Care (MOHLTC) Transformation Secretariat, with specific interest in the identification of value that Health Links add to the health system, such as avoided hospitalizations, reduced complications of care, improved quality of life, etc. In this report we: 1) describe the characteristics of the population in Health Links regions; 2) measure health system performance in HL regions using data held at the Institute for Clinical Evaluative Sciences (ICES), creating a portrait of HLs that can be used in the future; and 3) compare system performance among HLs and to existing physician networks (PN), defined by referral patterns among primary care physicians.

Methods Based on results from reports 1 and 2 in this series, twenty-two indicators were identified, defined, and categorized according to the Institute for Healthcare Improvement’s (IHI) Triple Aim framework: better care and experience for individuals, better health for populations, and lower growth in healthcare costs. Six of these indicators are the focus of this report:

1. average monthly costs, 2. the rate of hospitalization, 3. the rate of emergency-department visits for non-critical patients, 4. rate of 30-day readmissions, 5. primary care follow-up within 7 days of hospital discharge, 6. and the proportion of individuals rostered to a primary care physician.

Ontario residents with a valid health card on April 1, 2012 were assigned to an HL according to the location of their usual provider of primary care (90.2%) or home residence (9.8%), based on geographical boundaries defined by the MOHLTC. Using cohorts of 1) all Ontarians and 2) the top 5% high-cost users, indicator values for HLs were determined with data from the 2012 fiscal year.

Individual Health Link performance was compared to the provincial average across HLs for each of the indicators. HLs were categorized according to whether they adopted the initiative early or not (‘early adopters’), their degree of rurality according to the Rurality Index of Ontario (RIO), and measurable health inequities between geographical regions or populations according to the Ontario Marginalization Index (ON-Marg). A total Zscore using data from all indicators was created for HLs for both cohorts of interest to assess whether HLs were performing differently in the two populations.

Findings Demographic measures among HLs were comparable to provincial data for both the full population of residents and the top 5% of users. For the six selected indicators, a general comparison of HL performance to the provincial average did not reveal differences between early and later adopter HLs, but did reveal pockets of high and low performance. With respect to rurality, urban HLs had lower cost and lower ED-visit rates compared to the provincial average. Alternatively, suburban and rural HLs had higher rates of primary care rostering compared to the provincial average. Socio-economic status was found to be highly related to system performance indicators, with high levels of marginalization corresponding to lower performance, and a strong relationship between performance in the full population and among the top 5% of health care users. Although rural and low SES groups have lower performance than urban and high SES, there is substantial variation within these groupings, offering opportunities for comparative performance and potential learning from peer groups of HLs with similar local challenges. Comparisons showed substantial variation and overlap across all performance indicators for both Health Link and Physician Networks. We also found that there was only a moderate degree of overlap in patient populations between specific pairs of Health Links and Physician Networks. We examined the proportion of residents common to both the Health Link and the Physician Network that had the highest degree of overlap with each Health Link. We found that an average of only 46% of patients in Health Links overlapped with the Physician Network that shared the most patients in common.

Conclusions The performance of HLs on the indicators used for this report can inform benchmarking and be used for further analyses over time. Differences in performance based on rurality and marginalization highlight important contextual factors for HL leaders and decision makers to consider when comparing performance across HLs, particularly how to group HLs with appropriate peer-comparators. Identifying the specific effect of HLs on patient care and outcomes requires the ability to identify which individuals are enrolled in HL programs. A registry of Health Links patients is essential to any measurement of value of HLs or evaluation of performance of HLs on the heath of individuals and populations. This was not possible at the time of this report. Instead, the present report describes the general population trends of patients in HL geographies, but does not evaluate the performance of HLs specifically in regard to the patients who are enrolled in HL programs.

The Triple Aim Framework highlights a gap in the current focus of HL assessment: there are no indicators being used to track the performance of HLs on population health measures. Population health can have significant effects on health system performance measures, especially considering the results of the analyses based on rurality and marginalization.

Achieving effective inter-organizational integration across the care continuum is a challenging and important goal for Ontario’s health care system. Effective and timely approaches to identifying which patients to target for HL interventions and knowing which providers to engage will be key factors in the success of HLs. Differences in existing patterns of care for patients among PNs, compared to the geographic approach employed by HLs continue to present challenges for HLs to effectively manage care for complex patients. The model of Accountable Care Organizations described in the first report of this series could be pursued in Ontario based either on geographic boundaries, or enrolment models following existing practice patterns; it will be highly challenging to enable accountability and provide equitable funding with a hybrid approach. Full population-based accountability will require either that patients be willing to change primary care providers or that Health Links be reorganized to engage with providers in their referral network regardless of geography.

Table of Contents Executive Summary ...... 3 List of Tables ...... 7 List of Figures ...... 7 Context ...... 8 Objectives ...... 8 Methods ...... 8 Indicator Selection ...... 8 Indicator Definitions ...... 9 Study Period and Population ...... 12 Unit of Analysis: Health Links ...... 13 Physician Networks: Informal Networks for Comparison ...... 14 Data Analysis ...... 14 Findings ...... 15 1. Health Link Characteristics ...... 15 2. Health Link Performance Compared to Provincial Average ...... 16 3. Health Links compared to Physician Networks ...... 23 Conclusions ...... 30 References ...... 33 Appendices ...... 35

Appendix 1 – HSPRN Indicators used for assessing HLs Appendix 2 – Baseline demographic information for LHINs and HLs Appendix 3 –Baseline HL performance of early and later adopters, both cohorts: 22 indicators Appendix 4 –Baseline HL performance by rurality, both cohorts: 22 indicators Appendix 5 – Total Zscore comparison of HL performance in both cohorts by rurality: 22 indicators Appendix 6 –Baseline HL performance by marginalization quintile, both cohorts: 22 indicators Appendix 7 – League tables for HL and PN for 6 selected indicators by rurality: Both cohorts Appendix 8 – Overlap of individual Ontarians between HLs and PNs

List of Tables

Table 1 Health System Performance Research Network (HSPRN) Health System Value Indicators for HLs ...... 10 Table 2 Demographics for both cohorts of Ontarians, IKN assigned to HL and not...... 15 Table 3 Baseline performance of 22 early adopter HLs for 6 selected indicators: Full cohort...... 18 Table 4 Baseline performance of 32 later adopter HLs for 6 selected indicators: Full cohort...... Error! Bookmark not defined. Table 5 Baseline performance of 22 early adopter HLs for 6 selected indicators: Top 5% cohort...... Error! Bookmark not defined. Table 6 Baseline performance of 32 later adopter HLs for 6 selected indicators: Top 5% cohort...... Error! Bookmark not defined. Table 7 Number of HLs and PNs located in rural, suburban, and urban areas...... 20 Table 8 Urban HLs and PNs ranked by low acuity ED visit rate: Full cohort ...... 25 Table 9 Suburban HLs and PNs ranked by low acuity ED visit rate: Full cohort ...... 25 Table 10 Rural HLs and PNs ranked by low acuity ED visit rate: Full cohort ...... 25 Table 11 Urban HLs and PNs ranked by PC rostering: Full cohort ...... 26 Table 12 Suburban HLs and PNs ranked by PC rostering: Full cohort ...... 26 Table 13 Rural HLs and PNs ranked by PC rostering: Full cohort ...... 26 Table 14 Urban HLs and PNs ranked by low acuity ED visit rate: Top 5% ...... 27 Table 15 Suburban HLs and PNs ranked by low acuity ED visit rate: Top 5% ...... 27 Table 16 Rural HLs and PNs ranked by low acuity ED visit rate: Top 5% ...... 27 Table 17 Urban HLs and PNs ranked by PC rostering: Top 5% ...... 28 Table 18 Suburban HLs and PNs ranked by PC rostering: Top 5% ...... 28 Table 19 Rural HLs and PNs ranked by PC rostering: Top 5% ...... 28

List of Figures Figure 1 Total Zscore comparison of HLs by rurality for 6 selected indicators: Both cohorts ...... 22

Context Health Links (HLs) were announced in December 2012 as a means to improve the delivery of coordinated health care services for Ontarians, with an initial focus on complex, high-needs patients. Each HL is geographically defined and has the flexibility to create its own strategies to identify a target high-needs population, as well as strategies to improve integration of care. The first set of 22 ‘early adopter’ HLs commenced in late August 2013, and since then, more have been formed. Because HLs have flexibility in their design and each is at different stages of maturity, this report sought to measure HL performance on chosen indicators to establish a baseline portrait, which can be used to inform benchmarking.

Objectives This report utilizes population-based health administrative data from the province of Ontario to assess the performance of HLs on measurable indicators using data held at the Institute for Clinical Evaluative Sciences (ICES). At the time of writing, 54 HLs were defined by the Ministry of Health and Long-Term Care (MOHLTC), and complete administrative data was available through March 31, 2013. We report values for each HL in reference to provincial averages, by rurality, by marginalization index, and in comparison to 78 physician networks or PHYSNETs (PNs). These PNs are virtual networks of integrated care, based on observed patterns of health care seeking behaviours of patients as well as referral patterns among primary care physicians , specialists and hospitals previously identified from retrospective health administrative data (Stukel et al, 2013).

This report builds on our two prior reports about Health Links. The first of these compared the organization, goals, structure and performance measures used in Accountable Care Organizations to Ontario’s Health Links initiative. The second reported on data collected from interviews with Health Links leaders about what Health Links were doing to create value in the Ontario healthcare system. We used these reports to identify appropriate health system performance measures for Health Links.

We consider health system performance measurement following the Institute for Healthcare Improvement’s (IHI) Triple Aim framework of quality improvement, which includes the experience of individuals (including better care for individuals), the health of populations, and lowering cost growth (Institute for Healthcare Improvement, 2014). This framework covers a broad scope of the health care system and requires coordination at different levels, making it useful for assessing HLs.

Methods

Indicator Selection We identified relevant indicators, measurable with administrative data, within each category of the IHI Triple Aim framework. The indicators chosen to represent HL performance were informed by three sources:

1. Ministry of Health and Long-Term Care “indicators of success” for HLs,

2. Indicators used for Accountable Care Organizations (ACOs) in the United States, as outlined in the first report of this series (Mery and Wodchis, 2014), and 3. Areas of focus identified by HLs during interviews as outlined in the second report of this series (Mery, Kromm and Wodchis, 2015).

Only indicators that are currently measurable at the level of Health Links were included in this report. Twenty-two indicators were identified and are listed in Table 1 along with the source of the indicator. The current list captures two domains of the Triple Aim framework: ‘Better Care for Individuals’ and ‘Lower Growth in Health Care Costs’. We have not yet identified explicit measures for the third domain of ‘Better Health for Populations’. There are good measures of population health but current data collection from community health surveys are not sufficient to allow for sub-LHIN (i.e. Health Link) reporting in the same time frames as other indicators. In order to provide a more concise and focused portrait of HLs, this report focuses on 6 selected indicators (shaded in Table 1):

1. Average government costs per month alive, 2. Acute hospitalization rate, 3. Emergency department visit rate: low acuity, 4. Readmissions within 30 days for selected case mix groups (CMGs), 5. Patients with a Primary Care visit within 7 days of acute discharge: all individuals, and 6. Proportion of individuals rostered to a primary care physician.

These measures were selected as a parsimonious set of indicators that represent outcomes that would be relevant to all patients enrolled in Health Links (as opposed to only those with specific ages or a specific condition). The exception is the readmission rate, which applies only to hospitalized patients with one of 25 specific (common) conditions. Most respondents to our interviews identified readmissions as a high priority area and used this specific indicator, which is measured and monitored by the Ontario MOHLTC. Readmissions are also thought to be amenable to improved care coordination and care transitions, both of which are common areas of interest and activity for many Health Links. Early follow-up by physicians after hospital discharge is also one of the important measurable factors that might affect readmissions.

Indicator Definitions Administrative data housed at ICES were used to quantify all indicators. When possible, the MOHLTC Resource for Indicator Standards (RIS) website was used as a reference to define indicators from the available data (MOHLTC, 2014). This standardization of indicator definitions is important given the work that the MOHLTC is also carrying out with respect to quality measurement and assessing HLs and other areas of Ontario’s health care system. When indicator definitions were not available from the RIS page we sought definitions from other valid sources such as the Association of Public Health Epidemiologists in Ontario (APHEO), the Canadian Institute for Health Information (CIHI), and previous work carried out by experts from HSPRN or ICES.

Table 1 Health System Performance Research Network (HSPRN) Health System Value Indicators for HLs

Indicator/Metric Source LOWER GROWTH IN HEALTH CARE COSTS 1. Average government costs per year ACO Report (Value indicators – cost (age-sex standardized) containment) 2. Average government costs per month alive ACO Report (Value indicators – cost (age-sex standardized) containment) 3. Percent change in cost MOHLTC (Evaluation based metrics) BETTER CARE FOR INDIVIDUALS 4. Acute hospitalization rate (age-sex standardized) ACO Report 5. Acute hospitalization days (risk-adjusted) (Value indicators – appropriate resource use)

6. Avoidable ED visits for patients with conditions best MOHLTC (Results based metrics) managed elsewhere (age-sex standardized) Interviews with HL leaders Emergency department visit rate (age-sex standardized): 7. o All ED visits ACO Report 8. o High acuity/urgent ED visits (Value indicators – appropriate use of resources) 9. o Low acuity ED visits 10. Readmissions within 30 days for selected CMGs (risk- MOHLTC (Evaluation based metrics) adjusted) Interviews with HL leaders 11. Alternative Level of Care (ALC) days MOHLTC (Evaluation based metrics) Interviews with HL leaders Health related quality of life (HRQL) utility score 12. o Home Care Clients ACO Report (Quality indicators – better care) 13. o Long-Term Care Clients 14. Proportion of individuals rostered to a primary care MOHLTC (Operational metrics) physician (age-sex standardized) Interviews with HL leaders Patients with a Primary care visit within 7 days of acute discharge MOHLTC (Evaluation based metrics) 15. o All individuals 16. o Rostered individuals 17. Ambulatory Care Sensitive Conditions (ACSC) MOHLTC (Results based metrics) hospitalization rate (age-sex standardized) Interviews with HL leaders 18. ACSC hospital days (risk-adjusted) 19. Mental health & addictions hospitalization rate (age-sex Interviews with HL leaders standardized) 20. Long-term care admissions with a High/Very High MAPLe ACO Report Score (risk-adjusted) (Value indicators – appropriate use of resources)

21. Medication reconciliation within 14 days of hospital ACO Report (Quality indicators – better care) discharge (MedsCheck) 22. Appropriate care for diabetes (HbA1c, LDL, eye exam) ACO Report (Quality indicators – better care) BETTER HEALTH FOR POPULATIONS To Be Determined

Crude rates were calculated for all indicators. However, to enable comparisons across regions (HLs) and over time, we present adjusted rates, when applicable. Age-sex standardization was used for indicators derived from a population-based denominator, using the 1991 population of Canada as the reference population as per the protocol followed by the MOHLTC Health Analytics Branch. Other indicators were risk adjusted to control for age, sex, and other population-level attributes, making indicator measurement comparable across HLs.

Each of the 6 selected indicators is described below. The complete list of indicators, their definitions (data sources used and inclusion/exclusion criteria), and any standardization/adjustments made is provided in Appendix 1.

1. Average government costs (per month alive)

The first selected indicator is the average age-sex standardized cost per month alive. Total costs for each individual are divided by the total number of months they were alive in fiscal year 2012 (also known as person-months). All costing indicators are adjusted for inflation and reported in 2011 Canadian dollars.

2. Acute hospitalization rate

The second selected indicator is the age-sex standardized acute hospitalization rate which is based on hospital separations (including discharges, transfers and deaths). This definition is used by APHEO1 , and presented per 100,000 population. Mental health separations are excluded (a separate indicator is used to determine mental health-related admission rates).

3. Emergency department visit rate: low acuity

The third selected indicator is low-acuity emergency department (ED) visits. This indicator follows the MOHLTC definition2 provided on the RIS website, and includes all non-scheduled visits that do not result in an inpatient admission.

4. Readmissions within 30-days for selected case mix groups

The fourth selected indicator is the percentage of hospital discharges for selected CMGs that result in a readmission (any cause) within 30 days. This indicator follows the MOHLTC definition3. The CMGs include patients with an acute inpatient hospital stay for cardiac conditions, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, diabetes, stroke, and/or gastrointestinal disease. Consistent with past MOHLTC work, this indicator is risk-adjusted for age, sex, CMG, prior hospitalizations (within 1, 2, and 3 months), and comorbidity score (Charlson Index).

1 Association of Public Health Epidemiologists in Ontario (APHEO). (2009). “All-Cause Hospitalization.” Available from: http://www.apheo.ca/index.php?pid=93 2 Resource for Indicator Standards (RIS). (2010). Emergency visits by triage level. Available from: http://www.health.gov.on.ca/en/pro/programs/ris/docs/emergency_visits_by_triage_level_en.pdf 3 Resource for Indicator Standards (RIS). (2011). Readmissions for selected case mix groups (CMGs). Available from: http://www.health.gov.on.ca/en/pro/programs/ris/docs/readmissions_for_selected_case_mix_groups_cmgs.pdf

5. Patients with a primary care visit within 7 days of acute discharge: all individuals

This fifth indicator was selected to assess appropriate care transitions following discharge to reduce hospital readmissions (Baker, 2011) and was based on the MOHLTC definition4 but differed by including all individuals, not just those rostered to physicians. This indicator quantifies the proportion of all individuals discharged from acute care for a selected CMG who had a primary care follow up visit within 7 days of discharge. Physicians included those with a main specialty in family practice, general practice or pediatrics.

6. Proportion of individuals rostered to a primary care physician

The final selected indicator is the proportion of individuals rostered to a primary care physician, identified from the Client Agency Program Enrolment (CAPE) data. For this indicator we focus on individuals formally rostered to a physician, 70% of Ontarians. This aligns with step 1 of assigning individuals to HLs based on their rostered physician’s postal code (see below) and follows Ontario’s primary care reform initiative to increase continuity of care. We did not roster individuals to a usual provider of care (UPC) via virtual rostering (the physician seen most often by an individual two years prior to the index date) because we wanted to focus on formal rostering in order to determine whether there are differences between HLs and whether these differences could be correlated with performance on other indicators.

Study Period and Population The index date of April 1, 2012 was selected so that all indicators could be assessed and compared over a 1-year period using the most recent data available at ICES (fiscal year 2012, including data up to and including March 31, 2013). Our study included all residents of Ontario with a valid OHIP number as of April 1, 2012. Individuals were excluded if they were older than 105 years, or did not have any contact with the health care system after April 1, 2008. Indicator results were calculated for HLs and PNs based on two populations of interest:

1. All Ontarians 2. High-cost users – defined as the population with the top 5% of health care costs in the fiscal year prior to April 1, 2012

4 Resource for Indicator Standards (RIS). (2012). Patients with a primary care visit within 7 days of acute discharge for Quality Improvement Plans – Primary Care. Available from: http://www.health.gov.on.ca/en/pro/programs/ris/docs/patients_with_primary_care_visit_within_7_days_of_dis charge_qips_primary_care_en.pdf

Unit of Analysis: Health Links The focus of this research is to understand the performance of the 54 HLs geographically defined by their postal codes at the time of writing. A list of the HLs and their geographical boundaries was obtained from the MOHLTC and linked to data housed at ICES. From this linkage we assigned each Ontarian in the above populations to a HL in a three step process (in order):

1. Based on the postal code of the primary care physician an individual is rostered to (this captured 71.5% of Ontarians). 2. For individuals not rostered to a primary care physician the postal code of the usual provider of care (UPC, either a general practitioner, family physician, or pediatrician) that an individual visits most frequently within the two years prior to the index date (this captured another 18.7% of Ontarians). 3. For individuals not rostered to a physician and without a UPC we used the postal code of the individual’s residence (this captured the remaining 9.8% of Ontarians).

We linked Ontarians to a HL based on their primary care physician/UPC’s postal code because it is possible for a person to live in one HL but always receive care based on the model of another HL (the HL their primary care physician/UPC practices in). This is often the case in urban areas. Our data revealed that only 43.5% of urban-residing individuals lived in the same HL that their primary care physician/UPC practices (compared to 76.0% and 80.0% in suburban and rural areas, respectively). In some cases these two HL may be similar, but in other cases there may be significant differences. Linking individuals to a HL based on their primary care provider’s location allows us to capture the performance of HLs based on individuals receiving care from providers in that HL. The third step of this linking process, using the patient’s residential location, helps ensure that individuals living within the geographical boundaries of a HL, but not rostered to a physician or without a UPC, are captured and not grouped with Ontarians who live in areas of the province without a HL.

Rurality Index of Ontario

Each of the 54 HLs was categorized as urban, rural, or suburban based on the Rurality Index of Ontario (RIO) (Kralj, 2009). Index scores were determined by assigning a RIO level to distinct Ontario postal codes in the Registered Persons Database (RPDB)as of May 2011 (to match the MOHLTC HL boundary files). If a given postal code was assigned more than one unique RIO value, a weighted average (based on the population count from the RPDB) was calculated to derive a single RIO value for that postal code. These values are accurate at the time of writing. Should the MOHLTC update or change boundaries of HLs (e.g., more HLs are created) the RIO levels for existing HLs may change.

A medical geographer at ICES used ArcGIS mapping software to determine the geographical size (km2) of each postal code within a given HL. A weighted average RIO level was then determined for each of the HLs using the geographical size of the postal codes within the HL as weights. Following the rurality thresholds used by Stukel et al. (2013) for PNs, urban HLs were designated as those with an RIO score less than 10, suburban HLs as those with an RIO score of 10 to 39, and rural HLs as those with an RIO score greater than or equal to 40.

Ontario Marginalization Index

The Ontario Marginalization Index (ON-Marg) is used to show differences in marginalization between areas of Ontario and to understand inequalities between geographical areas (Matheson et al., 2012). The index takes four dimensions into account: residential instability, material deprivation, dependency, and ethnic concentration. Each dimension has a number of indicators used to provide a value for each dimension. These four dimensions can then be combined into a composite index or score. We followed the methodology of Matheson et al. (2012) to create a weighted average composite ON- Marg score for each HL using population counts as the weights. Five equal-sized groups (quintiles) were created based on the distribution of weighted values across the 54 HLs.

Physician Networks: Informal Networks for Comparison In order to understand the performance of HLs in relation to other potential integrated-care models, we compared indicator values from HLs to those of PNs (n=78). PHYSNETs are defined based on utilization and referral patterns among patients, primary care physicians, specialists, and institutions observed in health administrative data (Stukel et al., 2013). These multispecialty networks are distinct from formal physician care models in Ontario, such as Family Health Networks, Family Health Organizations, and others. PNs include physician and hospital care. Unlike HLs, PNs are not exclusively regionally based and have no geographical boundaries. Rather, they are based on patterns of existing patient flow. However, since our approach to identifying the target population for Health Links and the Physician Networks both assign patients to primary care providers (regardless of patients’ residence), HLs and PNs are similar in that they each include health care seeking behaviours of patients. The PN database at ICES provided RIO levels for all PNs.

Data Analysis The administrative data were analyzed to provide descriptive characteristics of HLs, compare the performance of HLs individually and as groups based on RIO and ON-Marg, and compared to PNs. Each analysis is described below along with the question it addresses:

1. What are the characteristics of HLs in Ontario?

Baseline demographic information for HLs was found and reported for all of Ontario, early adopter HLs (n=22), other HLs (n=32), and for the group of Ontario residents who are not currently linked to a HL by either their provider’s or own postal code. The demographic information is reported for the total population of Ontario and for the top 5% high cost users of Ontario’s health care system.

2. How does the performance of HLs compare to the provincial average for the selected indicators?

A comparative approach was taken to assess baseline performance of HLs. For both cohorts of interest (all Ontarians and high cost users), indicator values were derived for each of the 54 HLs and

values were compared to the overall provincial average for that cohort. HLs were also compared to the provincial average based on whether the HL was an early or later adopter, their categorization according to RIO score (rural, suburban, or urban), and five levels of Ontario’s marginalization index.

3. How do Health Links compare to PHYSNETs?

HLs were compared to the 78 PNs using a league table approach; each HL and PN were listed according to their indicator values for each of 6 selected indicators, from highest performer to lowest performer. We also examined the degree of overlap in the patient population between Health Links and PHYSNETs.

Findings Data analysis findings are presented in sections according to the three research questions. Each section presents the findings of analyses related to its corresponding research question.

1. Health Link Characteristics Baseline demographic information for the two populations of interest, early and later adopter HLs, and for individuals not linked to a HL are provided in Table 2 (see Appendix 2 for LHIN and individual HL level baseline demographic data). The current list of approved HLs captures 65.1% of the provincial population, and 65.6% of the cohort of top 5% high cost individuals. The data shows that HLs are comparable to provincial data for most criteria in both population cohorts (all Ontario and top 5%). The differences for the full cohort are that compared to individuals not linked to a HL, more individuals captured by a HL are enrolled in a primary care model, and the mean and median total costs for the fiscal year prior to April 1, 2012 are higher. For the top 5% cohort, the mean and median total costs for the fiscal year prior to April 1, 2012 are higher for individuals linked to a HL compared to those not linked to a HL.

Table 2 Demographics for both cohorts of Ontarians, IKN assigned to HL and not.

FULL POPULATION COHORT TOP 5% Ontario Early HL Other HL No HL Ontario Early HL Other HL No HL Total Population (N) 13,727,824 4,224,381 4,718,210 4,785,233 686,392 212,661 237,545 236,186 Male (%) 49.2 49.0 49.2 49.4 43.9 44.5 43.5 43.7 Age Median 39 40 39 40 66 66 66 67 Mean 39.7 39.8 39.4 39.9 62.4 61.9 62.2 63.1 Std 22.5 22.2 22.5 22.7 22.0 22.0 22.3 21.7 Enrolled in Primary Care model (%) 71.4 71.9 73.5 69.0 78.4 77.9 78.9 78.4 Resides in Long-Term Care (%) 0.6 0.6 0.7 0.6 12.4 11.9 12.8 12.4 Median income quintile 3 3 3 3 3 3 3 3 2+ chronic conditions (%) 26.6 26.4 26.7 26.8 80.0 79.2 79.8 80.8 Median total cost 1 year prior to $375 $381 $375 $352 $16,760 $16,713 $16,760 $16,674 index date Mean (Std) total cost 1 year prior to $2,261 $2,291 $2,277 $2,219 $28,717 $28,895 $28,736 $28,537 index date ($9,744) ($9,984) ($9,745) ($9,526) ($33,586) ($34,650) ($33,393) ($32,796) Top 5% high cost 5.0% 5.0% 5.0% 4.9% 100.0% 100.0% 100.0% 100.0%

2. Health Link Performance Compared to Provincial Average We compared the performance of HLs to the provincial average to assess the baseline performance of HLs on the 6 selected population level indicators:

1. Average monthly per capita cost (age/sex standardized), 2. Acute hospitalization rate per 100,000 individuals (age/sex standardized), 3. Low acuity emergency department visits per 100,000 individuals (age/sex standardized), 4. Readmission rate per 100,000 individuals (for 25 CMG, risk adjusted), 5. Percentage of primary care follow-up visits within 7 days of acute discharge, and 6. Proportion of individuals rostered to a primary care physician (age/sex standardized).

Tables 3 and 4 compare early and later adopter HLs to the provincial average for the full cohort of Ontarians and Tables 5 and 6 present the findings for the top 5% cohort. The first row of the four tables is the provincial average for that cohort and the second row is the average for the group of Ontarians who are not linked to one of the 54 HLs. HLs are sorted by their Local Health Integration Network (LHIN) in each table. Colour shading and other notations listed below are used to show how well early and later adopter HLs are performing compared to the provincial average for all Ontarians (Tables 3 and 4) or to the top 5% high cost users of health care (Tables 4 and 5) as follows:

- Shades of RED = values worse than the provincial average for the cohort. - Shades of GREEN = values better than the provincial average for the cohort. - Red asterisk = Network performing in the bottom 10 percent of all networks for that indicator. - Green asterisk = Network performing in the top 10 percent of all networks for that indicator. - Values that are significantly higher (lower) than the average at a five percent level of significance are indicated by an ‘H’ (‘L’) beside their score.

Sorting HLs by LHIN reveals pockets or areas of high (shades of green) and low (shades of red) performance throughout the province for the selected indicators. The baseline trends revealed by the data from these tables are highlighted below. The complete set of indicator results are presented in Appendix 3.

Baseline Trends

For the group of all Ontarians not currently linked to a HL (first row of Tables 3 and 4), indicator performance is significantly lower than or equivalent to the provincial average for average cost, acute hospitalization rate, 30-day readmission rate, follow-up within 7 days of acute care discharge, and proportion of individuals rostered to a primary care physician. This cohort of non-HL individuals performs significantly higher than the provincial average for low acuity ED visit rate. The tables do not show a difference in performance between early and later adopter HLs. There are high and low performers for both groups for all 6 selected indicators.

The first row of Tables 5 and 6 shows that the non-HL group of Ontarians who are in the cohort of top 5% high cost individuals have results higher or equivalent to the provincial average for acute hospitalization rate, low acuity ED visit rate, 30-day readmission rate, and proportion of individuals

rostered to a primary care physician. These tables also do not show a difference in performance between early and later adopter HLs. There are high and low performers for both groups for all 6 selected indicators.

Results displayed in these four tables (HLs grouped by LHIN) reveals pockets of high and low performance within LHINs. This shows that HLs within LHINs may perform better than the provincial average for some indicators, but never for all indicators. This finding holds for both cohorts of Ontarians and shows that the performance of HLs varies across the different indicators. As well, individual HLs may perform well (in the top 10% of HLs) on some indicators, but then poorly on other indicators. No HL is consistently a high or low performer.

Table 3 Baseline performance of 22 early adopter HLs for 6 selected indicators: Full cohort.

H = Significantly higher at 5% L = Significantly lower at 5% Top 10% = * Better than average Worse than average * = Bottom 10%

Crude Estimate Proportion Avg Std Monthly Cost Std Rate Acute Std Rate ED Visit: Low Risk-adj. Estimate (%) CMG All Individuals PC Follow-Up Std Proportion Rostered to LHIN # HEALTH LINK (**= early adopter) ($/person) Hospitalization (/100,000) Acuity (/100,000) Readmission Rate W/IN 7 days Acute PC Physician (%) Discharge (%)

All Ontario Cohort Average 166 5,618 15,664 15.1 32.3 71.3 NOT ASSIGNED 159 * L 5,526 * L 16,997 * H 14.9 * 30.3 * L 67.5 * L South West 2 Huron-Perth County** 162 * L 6,481 * H 38,980 * H 13.8 * 26.1 * L 83.0 * H Waterloo Wellington 3 Guelph** 155 * L 5,644 * 13,480 * L 14.7 * 30.8 * 72.3 * H HNHB 4 Hamilton Central** 202 * H 6,555 * H 16,063 * 16.3 * H 25.9 * L 72.2 * H Central West 5 Dufferin** 165 * H 6,550 * H 20,169 * H 13.0 * 27.1 * L 80.8 * H Central West 5 North Etobicoke-Malton-West Woodbridge** 157 * L 5,700 * H 7,345 * L 16.6 * H 39.9 * H 66.2 * L Mississauga Halton 6 East Mississauga** 149 * L 4,957 * L 9,419 * L 13.7 * L 37.6 * H 67.6 * L Toronto Central 7 Don Valley/Greenwood** 176 * H 5,171 * L 9,046 * L 16.1 * 32.2 * 70.7 * H Toronto Central 7 East Toronto** 176 * H 5,497 * 8,936 * L 16.6 * 35.1 * H 63.7 * L Toronto Central 7 Mid East Toronto** 177 * H 5,193 * L 10,731 * L 14.9 * 32.8 * 54.5 * L Toronto Central 7 Mid-West Toronto** 171 * H 5,036 * L 9,341 * L 15.2 * 32.0 * 61.9 * L Central 8 North York Central** 145 * L 4,574 * L 7,997 * L 14.9 * 35.2 * H 68.4 * L Central 8 South Simcoe and Northern York Region** 170 * H 5,969 * H 14,747 * L 15.8 * 40.4 * H 79.1 * H Central East 9 Peterborough** 179 * H 6,103 * H 22,745 * H 15.0 * 27.4 * L 76.6 * H South East 10 Kingston** 180 * H 5,386 * L 26,462 * H 16.3 * 33.0 * 81.2 * H South East 10 Quinte** 177 * H 6,007 * H 24,593 * H 15.4 * 30.2 * 80.7 * H South East 10 Rural Hastings** 176 * H 5,850 * H 33,560 * H 14.8 * 30.8 * 72.2 * H South East 10 Rural Kingston** 162 * L 5,599 * 30,550 * H 15.6 * 33.6 * 81.9 * H South East 10 Thousand Islands** 181 * H 6,382 * H 24,151 * H 14.5 * 30.9 * 78.2 * H North Simcoe Muskoka12 Barrie Community** 171 * H 5,835 * H 15,420 * L 14.8 * 25.7 * L 73.9 * H North Simcoe Muskoka12 South Georgian Bay Community** 157 * L 6,065 * H 24,373 * H 14.7 * 34.9 * H 82.9 * H North East 13 Cochrane South/Timmins** 203 * H 8,625 * H 55,546 * H 17.6 * H 24.9 * L 68.0 * L North East 13 Temiskaming** 194 * H 8,807 * H 80,451 * H 15.2 * 15.1 * L 55.2 * L

Table 4 Baseline performance of 32 later adopter HLs for 6 selected indicators: Full cohort.

Non - Early Adopter H = Significantly higher at 5% L = Significantly lower at 5% Top 10% = * Better than average Worse than average * = Bottom 10%

All Ontario Cohort Average 166 5,618 15,664 15.1 32.3 71.3 NOT ASSIGNED 159 * L 5,526 * L 16,997 * H 14.9 * 30.3 * L 67.5 * L Erie St. Clair 1 Chatham City Centre 193 * H 6,659 * H 28,793 * H 13.7 * 29.0 * 80.3 * H South West 2 London-Middlesex County 173 * H 5,856 * H 19,542 * H 16.7 * H 30.3 * 71.8 * H Waterloo Wellington 3 Cambridge 166 * H 5,537 * 13,316 * L 15.0 * 31.4 * 81.4 * H Waterloo Wellington 3 Kitchener-Waterloo 149 * L 4,784 * L 9,423 * L 12.8 * L 28.4 * L 71.9 * H Waterloo Wellington 3 Rural Wellington 156 * L 5,984 * H 34,765 * H 13.2 * 30.2 * 83.2 * H HNHB 4 Brantford, Brant & Six Nations 179 * H 6,669 * H 15,832 * L 16.2 * 30.1 * 78.0 * H HNHB 4 Burlington 156 * L 5,368 * L 10,227 * L 15.2 * 35.9 * H 80.7 * H HNHB 4 Haldimand 185 * H 6,533 * H 38,379 * H 14.3 * 33.4 * 81.9 * H HNHB 4 Hamilton East 187 * H 6,131 * H 16,394 * H 14.8 * 25.4 * L 75.3 * H HNHB 4 Hamilton West 182 * H 5,751 * H 14,225 * L 15.3 * 28.9 * L 80.4 * H HNHB 4 Niagara North East 178 * H 6,203 * H 14,954 * L 15.0 * 37.6 * H 72.2 * H HNHB 4 Niagara North West 159 * L 5,870 * H 19,384 * H 15.4 * 42.2 * H 84.5 * H HNHB 4 Niagara South East 178 * H 5,755 * H 15,065 * L 13.7 * 37.1 * H 71.7 * H HNHB 4 Niagara South West 173 * H 5,990 * H 22,238 * H 12.7 * L 38.6 * H 61.6 * L HNHB 4 Norfolk 177 * H 6,663 * H 27,154 * H 14.6 * 30.6 * 84.0 * H Central West 5 Bolton 157 * L 5,555 * 11,464 * L 12.8 * 41.8 * H 74.9 * H Central West 5 Bramalea 150 * L 5,614 * 7,323 * L 14.8 * 42.1 * H 68.9 * L Central West 5 Brampton 154 * L 5,657 * 8,105 * L 15.2 * 41.5 * H 73.6 * H Toronto Central 7 North Toronto East 161 * L 4,866 * L 8,082 * L 16.3 * 32.9 * 60.7 * L Toronto Central 7 South Toronto 173 * H 5,506 * 11,439 * L 15.8 * 33.6 * 55.0 * L Central 8 South West York Region 150 * L 4,889 * L 8,067 * L 14.6 * 39.3 * H 66.6 * L South East 10 Rideau Tay 169 * H 5,746 * 54,556 * H 14.5 * 21.4 * L 65.0 * L South East 10 Salmon River 189 * H 5,796 * 44,139 * H 16.1 * 28.3 * 70.0 * Champlain 11 Arnprior Region and Ottawa West 152 * L 5,007 * L 16,157 * 14.1 * 31.0 * 73.5 * H Champlain 11 Prescott-Russell Regional 182 * H 6,053 * H 32,696 * H 14.6 * 33.6 * 78.7 * H Champlain 11 South Renfrew 188 * H 6,401 * H 60,804 * H 12.2 * 28.7 * 64.7 * L Champlain 11 Upper Canada 164 * H 5,876 * H 16,526 * H 15.4 * 31.4 * 80.4 * H North Simcoe Muskoka12 Muskoka Community 167 * H 6,249 * H 32,598 * H 15.2 * 32.2 * 75.2 * H North Simcoe Muskoka12 North Simcoe Collaborative 197 * H 7,215 * H 39,560 * H 14.0 * 27.4 * L 78.1 * H North Simcoe Muskoka12 Orillia Community 176 * H 6,100 * H 36,870 * H 14.1 * 28.5 * L 77.3 * H North East 13 Cochrane North 203 * H 8,622 * H 119,934 * H 17.6 * 22.0 * L 61.2 * L North West 14 City of Thunder Bay 205 * H 7,675 * H 26,391 * H 16.1 * 20.9 * L 68.7 * L 18

Table 5 Baseline performance of 22 early adopter HLs for 6 selected indicators: Top 5% cohort.

Early Adopter H = Significantly higher at 5% L = Significantly lower at 5% Top 10% = * Better than average Worse than average * = Bottom 10%

Top 5% Cohort Average 1,222 29,122 37,470 20.5 32.3 71.9 NOT ASSIGNED 1,185 * L 29,103 * 42,824 * H 20.5 * 30.3 * L 71.9 * South West 2 Huron-Perth County** 1,212 * H 37,705 * H 80,191 * H 19.4 * 26.4 * L 86.4 * H Waterloo Wellington 3 Guelph** 1,135 * L 27,638 * 31,340 * L 18.7 * 30.8 * 67.6 * L HNHB 4 Hamilton Central** 1,542 * H 30,731 * 35,226 * L 21.3 * 25.4 * L 69.9 * Central West 5 Dufferin** 996 * L 29,031 * 37,240 * 18.6 * 28.4 * 85.2 * H Central West 5 North Etobicoke-Malton-West Woodbridge** 1,110 * L 31,132 * 17,893 * L 23.0 * H 37.4 * H 71.0 * Mississauga Halton 6 East Mississauga** 1,116 * L 27,674 * 20,514 * L 19.6 * 36.3 * H 70.5 * Toronto Central 7 Don Valley/Greenwood** 1,426 * H 24,529 * L 28,332 * L 22.7 * 33.0 * 68.8 * Toronto Central 7 East Toronto** 1,248 * H 28,831 * 24,855 * L 22.6 * 36.8 * H 69.1 * Toronto Central 7 Mid East Toronto** 1,347 * H 27,600 * 29,990 * L 20.5 * 34.2 * 63.1 * L Toronto Central 7 Mid-West Toronto** 1,572 * H 33,081 * H 22,301 * L 20.9 * 32.6 * 58.0 * L Central 8 North York Central** 1,160 * L 25,904 * L 18,659 * L 20.8 * 35.5 * H 70.3 * Central 8 South Simcoe and Northern York Region** 1,122 * L 27,637 * 36,540 * L 21.4 * 42.0 * H 84.2 * H Central East 9 Peterborough** 1,141 * L 27,614 * 44,854 * H 19.2 * 29.0 * 68.6 * South East 10 Kingston** 1,292 * H 30,606 * 68,139 * H 22.4 * 34.5 * 80.0 * H South East 10 Quinte** 1,028 * L 26,166 * L 51,923 * H 20.1 * 29.8 * 82.1 * H South East 10 Rural Hastings** 1,013 * L 23,734 * L 62,029 * H 20.9 * 31.9 * 75.9 * South East 10 Rural Kingston** 830 * L 21,894 * L 82,219 * H 21.4 * 32.5 * 82.3 * South East 10 Thousand Islands** 1,157 * L 27,969 * 62,885 * H 19.9 * 34.5 * 75.9 * North Simcoe Muskoka12 Barrie Community** 1,102 * L 27,617 * 35,110 * L 17.7 * L 25.6 * L 71.7 * North Simcoe Muskoka12 South Georgian Bay Community** 983 * L 34,419 * H 40,346 * 17.9 * 33.8 * 86.1 * H North East 13 Cochrane South/Timmins** 993 * L 32,884 * H 127,562 * H 22.2 * 24.6 * L 70.0 * North East 13 Temiskaming** 1,029 * L 36,214 * H 160,097 * H 19.7 * 20.5 * L 59.8 * L

Table 6 Baseline performance of 32 later adopter HLs for 6 selected indicators: Top 5% cohort.

Non - Early Adopter H = Significantly higher at 5% L = Significantly lower at 5% Top 10% = * Better than average Worse than average * = Bottom 10%

Top 5% Cohort Average 1,222 29,122 37,470 20.5 32.3 71.9

NOT ASSIGNED 1,185 * L 29,103 * 42,824 * H 20.5 * 30.3 * L 71.9 * Erie St. Clair 1 Chatham City Centre 1,431 * H 33,248 * 57,515 * H 17.6 * 30.6 * 80.0 * H South West 2 London-Middlesex County 1,367 * H 33,050 * H 45,519 * H 22.7 * H 30.7 * 66.8 * L Waterloo Wellington 3 Cambridge 1,311 * H 30,567 * 26,961 * L 19.6 * 33.3 * 78.5 * H Waterloo Wellington 3 Kitchener-Waterloo 1,211 * H 26,128 * L 24,684 * L 17.0 * L 27.5 * L 69.3 * Waterloo Wellington 3 Rural Wellington 1,194 * L 25,253 * L 72,310 * H 17.0 * 29.1 * 82.8 * H HNHB 4 Brantford, Brant & Six Nations 1,151 * L 31,347 * 32,145 * L 20.2 * 31.1 * 76.3 * H HNHB 4 Burlington 1,095 * L 26,525 * L 24,742 * L 21.4 * 33.8 * 83.3 * H HNHB 4 Haldimand 1,082 * L 26,702 * 67,055 * H 16.8 * 31.7 * 88.1 * H HNHB 4 Hamilton East 1,404 * H 30,554 * 25,791 * L 19.5 * 24.2 * L 76.5 * H HNHB 4 Hamilton West 1,431 * H 28,728 * 31,422 * L 19.5 * 27.9 * L 77.4 * H HNHB 4 Niagara North East 1,198 * L 30,943 * 39,469 * 21.7 * 38.8 * H 73.3 * HNHB 4 Niagara North West 1,063 * L 24,612 * L 36,355 * 19.0 * 39.2 * H 84.9 * H HNHB 4 Niagara South East 1,181 * L 25,960 * L 33,316 * L 18.7 * 36.4 * H 73.6 * HNHB 4 Niagara South West 1,102 * L 30,412 * 41,479 * 16.3 * L 38.0 * H 64.0 * L HNHB 4 Norfolk 1,192 * L 31,060 * 52,217 * H 18.6 * 33.0 * 90.6 * H Central West 5 Bolton 920 * L 27,270 * 22,959 * L 15.4 * 39.6 * H 79.7 * H Central West 5 Bramalea 1,056 * L 30,751 * 15,791 * L 22.5 * 38.0 * H 76.7 * H Central West 5 Brampton 1,050 * L 29,778 * 18,350 * L 21.5 * 38.9 * H 78.0 * H Toronto Central 7 North Toronto East 1,297 * H 24,943 * L 18,231 * L 20.6 * 36.5 * H 61.5 * L Toronto Central 7 South Toronto 1,387 * H 33,157 * H 31,347 * L 22.0 * 33.2 * 59.8 * L Central 8 South West York Region 1,067 * L 25,239 * L 23,677 * L 20.5 * 38.2 * H 66.4 * L South East 10 Rideau Tay 1,203 * L 30,057 * 109,482 * H 22.2 * 25.9 * L 70.9 * South East 10 Salmon River 1,456 * H 28,788 * 92,621 * H 23.6 * 25.8 * 69.7 * Champlain 11 Arnprior Region and Ottawa West 1,102 * L 23,454 * L 32,741 * L 18.3 * 32.1 * 75.1 * Champlain 11 Prescott-Russell Regional 1,183 * L 24,210 * L 61,070 * H 20.1 * 35.9 * 79.6 * H Champlain 11 South Renfrew 1,220 * H 23,059 * L 126,513 * H 16.8 * 31.0 * 71.6 * Champlain 11 Upper Canada 1,123 * L 28,197 * 32,852 * L 21.2 * 30.9 * 80.6 * H North Simcoe Muskoka12 Muskoka Community 1,010 * L 24,401 * L 70,276 * H 17.0 * 30.3 * 77.3 * North Simcoe Muskoka12 North Simcoe Collaborative 1,271 * H 29,616 * 73,686 * H 18.7 * 28.1 * 76.2 * North Simcoe Muskoka12 Orillia Community 1,135 * L 25,367 * L 87,272 * H 17.6 * 25.1 * L 77.6 * H North East 13 Cochrane North 1,149 * L 30,393 * 268,008 * H 25.0 * 19.0 * L 65.6 * North West 14 City of Thunder Bay 1,227 * H 36,146 * H 56,065 * H 22.3 * 20.6 * L 63.8 * L 19

Rurality Index of Ontario

Each HL was given an RIO level as described in the methods. Table 7 shows the distribution of HLs in rural, suburban, and urban areas. The data for PNs is also provided for comparison purposes. A higher percentage of PNs are urban (56%) compared to HLs (33%), whereas the percentage of HLs that are rural and suburban is higher than for PNs.

Table 7 Number of HLs and PNs located in rural, suburban, and urban areas.

Health Links Physician Early Adopter Later Adopter Total Networks Rural (RIO≥40) 6 5 11 11 Suburban (10≤RIO<40) 8 17 25 23 Urban (RIO<10) 8 10 18 44 Total 22 32 54 78

Comparisons of urban HL performance to the provincial average using the full cohort of Ontarians reveals urban HLs were more likely to be high performers for the indicators of monthly costs and rates of low acuity ED. Suburban and rural HLs were more likely to be lower performers for these two indicators. Suburban and rural HLs were more likely to be high performers compared to the provincial average for primary care rostering, whereas urban HLs were more likely to be lower performers. Results for all indicators and HLs by rurality can be found in Appendix 4.

The cohort of top 5% high cost individuals revealed different patterns. For example, monthly costs were more likely to be lower (higher) than the provincial average in suburban and rural (urban) HLs. As well, primary care rostering for the top 5% cohort in urban HLs was more likely to be higher than the provincial average. Results for all HLs and indicators for the top 5% cohort are found in Appendix 4.

Comparing Health Links: Full Population versus Top 5% Population

In order to compare how urban, suburban, and rural HLs are performing in both the full and top 5% cohorts, we created an aggregate score based on the sum of HL indicator performance for their full population and their population of top 5% high cost individuals for the 6 selected indicators. We based this aggregate score on the Zscore commonly used in statistics. While the Zscore is used for normally distributed data, we are using it because it takes into account both the mean and standard deviation, controlling for difference and dispersion, creating a standardized score.

The total Zscore is found using equation 1. It is made up of two Zscore formulas in order to take into account whether being higher than the mean indicates higher performance or whether being lower than the mean indicates higher performance. For four of the selected indicators (Zi) a below average performance is better, whereas for the other two indicators (Zj) above average performance is better.

Zi = indicator i, below average is better xk = Health Link k’s performance

Zj = indicator j, above average is better µ = mean

σ = standard deviation

�! − �! �! = �!

��!"!#$ = [ −1 �! + �!] (Equation 1)

The comparison based on the total Zscore for both populations of individuals is presented in Figure 1; the y-axis is the total Zscore for the top 5% population and the x-axis is total Zscore for the full population. When the results for both cohorts are plotted for all HLs we found that the majority of HLs fall in quadrants 1, 2, and 4. HLs in quadrant 1 are performing better than the provincial average in their top 5% cohort. HLs in quadrant 2 are performing better than the provincial average for both cohorts. HLs in quadrant 4 are performing worse than the provincial average for both cohorts. It is notable that there is more dispersion from the mean in quadrant 4 (poor performance) compared to the variation found in the other quadrants (points are closer to the origin, indicating performance closer to the provincial average).

Figure 1 also contains a 45 degree line (dotted) denoting when the total Zscore for the HL’s cohort of top 5% high cost individuals is equal to the total Zscore for the HL’s full population. This 45 degree line helps us compare the relative performance of HLs in these two cohorts. Points below the 45 degree line in quadrant 2 indicate that performance is better in the full population compared to the cohort of top 5% individuals in that HL based on the 6 selected indicators. Points above the 45 degree line in quadrant 4 indicate that those HLs are performing better in their top 5% populations compared to their full cohort for the 6 selected indicators. Our findings also show that urban HLs are more likely to perform comparably well in both populations (total Zscore points are close to the 45 degree line in all quadrants). Conversely, points for rural and suburban HLs are more likely to be in quadrants 1 and 2, indicating that they perform better in their top 5% population compared to their full cohort. Comparable results were found when all 22 indicators were used to calculate the total Zscore (see Figure A5.1 in Appendix 5).

Figure 1 Total Zscore comparison of HLs by rurality for 6 selected indicators: Both cohorts

urban Q1 Q2 suburban Beer in top 5% Beer in both populaon populaons

rural

Aggregate performance (full HL pop.)

Q4 Q3 Lower performance Beer performance in in both populaons total populaon Aggregate performance (Top 5% pop.)

Ontario Marginalization Index

Grouping HLs based on their marginalization index on a scale of 1 (lowest marginalization) to 5 (highest marginalization) revealed that marginalization is a predictor of performance in both populations of interest. HLs in the highest quintile of marginalization were more likely to perform lower than the provincial average for primary care follow-up and rostering, and higher than the provincial average for the other four selected indicators. The opposite is true for HLs in the lowest quintile of marginalization. In the cohort of top 5% high cost individuals, the effect of marginalization is not as strong. These findings can be found in Appendix 6.

3. Health Links compared to Physician Networks The patient populations of PNs and HLs are not exactly the same: all 78 PNs together capture over 12 million Ontarians and the 54 HLs capture almost 9 million Ontarians. Even so, comparing indicator results from HLs to that of PNs can provide information that can be used when deciding how population level (as opposed to targeted population) models of care should be designed.

League Table Comparison of Health Links and Physician Networks

In order to explore how HLs and PNs rank in relationship to each other, with respect to their performance against the provincial average, we created combined league tables for each indicator. The league tables list HLs and PNs in order of performance, from highest to lowest performance. This comparison provides data regarding how the early and later HLs compare to the networks of providers across Ontario including in geographies where HLs are not yet implemented. For this table residents who are in HLs are also represented in PNs. The degree of this overlap is examined and displayed in Appendix 8. For the comparison of HL and PN we examined results in both the overall Ontario population and in the top 5% cohorts and stratified the results by rurality (urban, suburban and rural). Because of these multiple populations and stratifications, results for only 2 of the 6 selected indicators are presented in Tables 8 to 19. The two indicators, low acuity ED visits and primary care rostering, were chosen for the body of the report because they are examples of the variation in performance for HLs and PNs, for early adopter HLs, and HLs and PNs based on rurality. The remaining four indicator results are provided in Appendix 7.

The colour shading in the league tables corresponds to how well a HL or PN is performing at baseline compared to the provincial average for all Ontarians (Tables 8 to 13) or to the provincial average of all top 5% high cost individuals (Tables 14 to 19):

HLs and PNs are listed in order of performance compared to the provincial average, from highest performance (darkest shade of green) to lowest performance (darkest shade of red). The names of the 78 PNs are in all caps and the names of the 22 early adopter HLs are shaded.

These tables show that both HLs and PNs are distributed throughout the rurality league tables regardless of type (HL or PN). Nonetheless, for the cohort of all Ontarians, HLs are more likely to be represented near the top (better performance) of the league table for ED visits in all geographic

groupings, and in the urban league table HLs are more likely to be represented near the bottom. It is notable that urban HLs and PNs are more likely to be shaded green, indicating baseline performance that is better than the provincial average – particularly for ED visits. Rural HLs and PNs are more likely to perform below the provincial average in the cohort of all Ontarians. This pattern of better performance in urban areas compared to suburban and rural areas for both HLs and PNs is also true for the full Ontario population for ACSC hospitalizations (Appendix 7). For other indicators there are few systematic differences across rurality.

In the cohort of top 5% high cost individuals, the same pattern of findings by geography (better performance in urban than rural areas) was observed for low-acuity ED visits (Tables 14-16) but for all other indicators (below and in Appendix 7) performance across urban, suburban, and rural groupings is more varied, with both high and low performers (green and red shading) found regardless of rurality. One exception being that early adopter HLs in urban areas tended to have lower rates of enrolment with PC in urban areas.

When individual PNs or HLs are observed across the different league tables (below and in Appendix 7), no HL or PN is the highest performer in both cohorts of Ontarians (full and top 5% high cost individuals), or for all indicators in either cohort.

Table 8 Urban HLs and PNs ranked by low acuity ED visit rate: Full Table 9 Suburban HLs and PNs ranked by low acuity ED visit rate: cohort Full cohort Std Rate ED Visit: Low Std Rate ED Visit: Low Health Link / PHYSICIAN NETWORK Health Link / PHYSICIAN NETWORK Acuity (/100,000) Acuity (/100,000) All Ontario cohort 16,123 All Ontario cohort 16,123 SCARBOROUGH HOSPITAL (THE)-GRACE SITE 6,774 * L South West York Region Health Link 8,067 * L Bramalea Health Link 7,323 * L Kitchener-Waterloo Health Link 9,423 * L North Etobicoke-Malton-West Woodbridge Health Link** 7,345 * L Cambridge Health Link 13,316 * L WILLIAM OSLER HEALTH SYSTEM-ETOBICOKE 7,899 * L Guelph Health Link** 13,480 * L North York Central Health Link ** 7,997 * L South Simcoe and Northern York Health Link** 14,747 * L North Toronto East Health Link 8,082 * L Niagara North East Health Link 14,954 * L Brampton Health Link 8,105 * L Niagara South East Health Link 15,065 * L HUMBER RIVER REGIONAL HOSP-YORK-FINCH 8,312 * L SOUTHLAKE REGIONAL HEALTH CENTRE 15,397 * L YORK CENTRAL HOSPITAL 8,331 * L Barrie Community Health Link** 15,420 * L WILLIAM OSLER HEALTH CENTRE-BRAMPTON 8,373 * L Brantford, Brant & Six Nations Health Link 15,832 * L HOSPITAL FOR SICK CHILDREN (THE) 8,468 * L Upper Canada Health Link 16,526 * H CREDIT VALLEY HOSPITAL (THE) 8,493 * L LEAMINGTON DISTRICT MEMORIAL HOSPITAL 18,460 * H NORTH YORK GENERAL HOSPITAL 8,788 * L HEADWATERS HEALTH CARE CENTRE-DUFFERIN 18,833 * H East Toronto Health Link** 8,936 * L Niagara North West Health Link 19,384 * H Don Valley/Greenwood Health Link** 9,046 * L London-Middlesex County Health Link 19,542 * H SUNNYBROOK HEALTH SCIENCES CENTRE 9,219 * L Dufferin Health Link** 20,169 * H TORONTO EAST GENERAL HOSPITAL 9,331 * L NORTHUMBERLAND HILLS HOSPITAL 21,149 * H Mid-West Toronto Health Link** 9,341 * L Niagara South West Health Link 22,238 * H East Mississauga Health Link** 9,419 * L BROCKVILLE GENERAL HOSPITAL 23,934 * H HUMBER RIVER REGIONAL HOSP-HUMBER MEM 9,547 * L Thousand Islands Health Link** 24,151 * H UNIVERSITY HEALTH NETWORK 9,588 * L Quinte Health Link** 24,593 * H SCARBOROUGH HOSPITAL (THE)-SCAR.GEN.SITE 9,708 * L COLLINGWOOD GENERAL AND MARINE HOSPITAL 25,078 * H MOUNT SINAI HOSPITAL 9,927 * L Kingston Health Link** 26,462 * H Burlington Health Link 10,227 * L QUINTE HEALTHCARE CORPORATION-BELLEVILLE 26,794 * H GRAND RIVER HOSPITAL CORP-WATERLOO SITE 10,228 * L NORFOLK GENERAL HOSPITAL 26,827 * H ROUGE VALLEY HEALTH SYSTEM-CENTENARY 10,361 * L PETERBOROUGH REGIONAL HEALTH CENTRE 26,892 * H Mid East Toronto Health Link** 10,731 * L Norfolk Health Link 27,154 * H TRILLIUM HEALTH CENTRE-MISSISSAUGA 10,793 * L NIAGARA HEALTH SYSTEM-WELLAND COUNTY 27,666 * H ST MICHAEL'S HOSPITAL 10,815 * L ST THOMAS-ELGIN GENERAL HOSPITAL 28,128 * H OTTAWA HOSPITAL ( THE )-GENERAL SITE 10,856 * L SAULT AREA HOSPITAL-SAULT STE MARIE 28,223 * H MARKHAM STOUFFVILLE HOSPITAL 10,878 * L Chatham City Centre Health Link 28,793 * H JOSEPH BRANT MEMORIAL HOSPITAL 11,070 * L PUBLIC GENERAL HOSP SOCIETY OF CHATHAM 32,100 * H CHILDREN'S HOSPITAL OF EASTERN ONTARIO 11,078 * L CORNWALL COMMUNITY HOSPITAL 33,227 * H WINDSOR REGIONAL HOSPITAL-METROPOLITAN 11,303 * L Rural Wellington Health Link 34,765 * H HALTON HEALTHCARE SERVICES CORP-OAKVILLE 11,371 * L OTTAWA SATELLITE NETWORK 34,829 * H ST JOSEPH'S HEALTH CENTRE 11,428 * L WOODSTOCK GENERAL HOSPITAL 36,543 * H South Toronto Health Link 11,439 * L ORILLIA SOLDIERS' MEMORIAL HOSPITAL 37,541 * H Bolton Health Link 11,464 * L Haldimand Health Link 38,379 * H OTTAWA HOSPITAL ( THE )-CIVIC SITE 12,089 * L North Simcoe Collaborative Heath Link 39,560 * H HOTEL-DIEU GRACE HOSPITAL-ST JOSEPH'S 12,533 * L ROSS MEMORIAL HOSPITAL 40,040 * H ROUGE VALLEY HEALTH SYSTEM-AJAX SITE 13,640 * L Salmon River Health Link 44,139 * H HOPITAL REGIONAL DE SUDBURY-LAURENTIAN 13,786 * L BLUEWATER HEALTH-SARNIA GENERAL SITE 45,464 * H CAMBRIDGE MEMORIAL HOSPITAL 13,934 * L TIMMINS & DISTRICT GENERAL HOSPITAL 46,428 * H QUEENSWAY-CARLETON HOSPITAL 14,051 * L NORTH BAY GENERAL HOSP-CIVIC/ST JOSEPH'S 48,349 * H Hamilton West Health Link 14,225 * L Rideau Tay Health Link 54,556 * H NIAGARA HEALTH SYSTEM-GREATER NIAGARA 15,513 * L PERTH & SMITHS FALLS DISTRICT HOSPITAL 56,791 * H Hamilton Central Health Link** 16,063 * WEENEEBAYKO GENERAL HOSPITAL 60,706 * H Arnprior Region and Ottawa West Health Link 16,157 * Temiskaming Health Link** 80,451 * H Hamilton East Health Link 16,394 * H ROYAL VICTORIA HOSPITAL OF BARRIE (THE) 16,766 * H BRANT COMMUNITY HEALTHCARE SYS-BRANTFORD 16,803 * H Table 10 Rural HLs and PNs ranked by low acuity ED visit rate: Full NIAGARA HEALTH SYSTEM-ST CATHARINES GEN 16,878 * H cohort LAKERIDGE HEALTH CORPORATION-OSHAWA SITE 16,927 * H Std Rate ED Visit: Low Health Link / PHYSICIAN NETWORK HAMILTON HEALTH SCIENCES CORP-MCMASTER 16,937 * H Acuity (/100,000) ST JOSEPH'S HEALTH CARE SYSTEM-HAMILTON 17,282 * H All Ontario cohort 16,123 HOPITAL MONTFORT 17,729 * H Peterborough Health Link** 22,745 * H CENTRE FOR ADDICTION & MENTAL HEALTH-ARF 18,729 * H South Georgian Bay Community Health Link** 24,373 * H LONDON HLTH SCIENCES CTR-UNIVERSITY HOSP 20,521 * H Rural Kingston Health Link** 30,550 * H GUELPH GENERAL HOSPITAL 20,748 * H Muskoka Community Health Link 32,598 * H City of Thunder Bay Health Link 26,391 * H MUSKOKA ALGONQUIN HEALTHCARE- 32,650 * H THUNDER BAY REGIONAL HLTH SCIENCES CTR 27,861 * H HUNTSVILLE KINGSTON GENERAL HOSPITAL 29,406 * H Prescott-Russell Regional Health Link 32,696 * H **early adopter Health Link Rural Hastings Health Link** 33,560 * H Orillia Community Health Link 36,870 * H STRATFORD GENERAL HOSPITAL 38,916 * H Huron-Perth County Health Link** 38,980 * H GEORGIAN BAY 40,498 * H GREY BRUCE HEALTH SERVICES-OWEN SOUND 44,052 * H THUNDER BAY SATELLITE NETWORK-NW 44,654 * H PEMBROKE REGIONAL HOSPITAL INC 54,677 * H Cochrane South/Timmins Health Link** 55,546 * H THUNDER BAY SATELLITE NETWORK-SOUTH 57,575 * H South Renfrew Health Link 60,804 * H SUDBURY SATELLITE NETWORK 71,168 * H OWEN SOUND SATELLITE NETWORK-SOUTH 78,240 * H THUNDER BAY SATELLITE NETWORK-EAST 86,946 * H TIMMINS SATELLITE NETWORK 97,511 * H Cochrane North Health Link 119,934 * H 25

Table 11 Urban HLs and PNs ranked by PC rostering: Full cohort Table 12 Suburban HLs and PNs ranked by PC rostering: Full cohort Std Proportion Std Proportion Health Link / PHYSICIAN NETWORK Rostered to PC Health Link / PHYSICIAN NETWORK Rostered to PC Physician Physician All Ontario cohort 70.0 All Ontario cohort 70.0 KINGSTON GENERAL HOSPITAL 84.7 * H NORFOLK GENERAL HOSPITAL 88.4 * H JOSEPH BRANT MEMORIAL HOSPITAL 84.7 * H WOODSTOCK GENERAL HOSPITAL 87.8 * H CAMBRIDGE MEMORIAL HOSPITAL 84.2 * H OTTAWA SATELLITE NETWORK 86.8 * H HOPITAL MONTFORT 82.6 * H COLLINGWOOD GENERAL AND MARINE HOSPITAL 86.5 * H HALTON HEALTHCARE SERVICES CORP-OAKVILLE 82.1 * H NORTHUMBERLAND HILLS HOSPITAL 85.3 * H BRANT COMMUNITY HEALTHCARE SYS-BRANTFORD 81.6 * H Niagara North West Health Link 84.5 * H Burlington Health Link 80.7 * H Norfolk Health Link 84.0 * H Hamilton West Health Link 80.4 * H Rural Wellington Health Link 83.2 * H LAKERIDGE HEALTH CORPORATION-OSHAWA SITE 80.2 * H ST THOMAS-ELGIN GENERAL HOSPITAL 82.5 * H HAMILTON HEALTH SCIENCES CORP-MCMASTER 79.5 * H QUINTE HEALTHCARE CORPORATION-BELLEVILLE 82.0 * H ROUGE VALLEY HEALTH SYSTEM-AJAX SITE 79.5 * H Haldimand Health Link 81.9 * H NIAGARA HEALTH SYSTEM-ST CATHARINES GEN 79.2 * H LEAMINGTON DISTRICT MEMORIAL HOSPITAL 81.8 * H QUEENSWAY-CARLETON HOSPITAL 79.1 * H SOUTHLAKE REGIONAL HEALTH CENTRE 81.7 * H GUELPH GENERAL HOSPITAL 78.9 * H HEADWATERS HEALTH CARE CENTRE-DUFFERIN 81.6 * H NIAGARA HEALTH SYSTEM-GREATER NIAGARA 78.8 * H Cambridge Health Link 81.4 * H ST JOSEPH'S HEALTH CARE SYSTEM-HAMILTON 78.3 * H Kingston Health Link** 81.2 * H ROYAL VICTORIA HOSPITAL OF BARRIE (THE) 77.4 * H PETERBOROUGH REGIONAL HEALTH CENTRE 80.9 * H SCARBOROUGH HOSPITAL (THE)-GRACE SITE 77.4 * H Dufferin Health Link** 80.8 * H MARKHAM STOUFFVILLE HOSPITAL 76.5 * H Quinte Health Link** 80.7 * H WILLIAM OSLER HEALTH CENTRE-BRAMPTON 76.1 * H PUBLIC GENERAL HOSP SOCIETY OF CHATHAM 80.4 * H GRAND RIVER HOSPITAL CORP-WATERLOO SITE 76.0 * H Upper Canada Health Link 80.4 * H CREDIT VALLEY HOSPITAL (THE) 76.0 * H ORILLIA SOLDIERS' MEMORIAL HOSPITAL 80.3 * H ROUGE VALLEY HEALTH SYSTEM-CENTENARY 75.9 * H Chatham City Centre Health Link 80.3 * H LONDON HLTH SCIENCES CTR-UNIVERSITY HOSP 75.6 * H BROCKVILLE GENERAL HOSPITAL 79.3 * H OTTAWA HOSPITAL ( THE )-GENERAL SITE 75.6 * H South Simcoe and Northern York Health Link** 79.1 * H Hamilton East Health Link 75.3 * H Thousand Islands Health Link** 78.2 * H HOTEL-DIEU GRACE HOSPITAL-ST JOSEPH'S 75.1 * H North Simcoe Collaborative Heath Link 78.1 * H Bolton Health Link 74.9 * H Brantford, Brant & Six Nations Health Link 78.0 * H HUMBER RIVER REGIONAL HOSP-HUMBER MEM 74.2 * H BLUEWATER HEALTH-SARNIA GENERAL SITE 77.5 * H Brampton Health Link 73.6 * H SAULT AREA HOSPITAL-SAULT STE MARIE 76.5 * H SUNNYBROOK HEALTH SCIENCES CENTRE 73.5 * H ROSS MEMORIAL HOSPITAL 74.3 * H Arnprior Region and Ottawa West Health Link 73.5 * H Barrie Community Health Link** 73.9 * H NORTH YORK GENERAL HOSPITAL 73.1 * H TIMMINS & DISTRICT GENERAL HOSPITAL 72.8 * H UNIVERSITY HEALTH NETWORK 72.9 * H Guelph Health Link** 72.3 * H THUNDER BAY REGIONAL HLTH SCIENCES CTR 72.2 * H Niagara North East Health Link 72.2 * H Hamilton Central Health Link** 72.2 * H NORTH BAY GENERAL HOSP-CIVIC/ST JOSEPH'S 72.2 * H TRILLIUM HEALTH CENTRE-MISSISSAUGA 71.6 * H Kitchener-Waterloo Health Link 71.9 * H HOPITAL REGIONAL DE SUDBURY-LAURENTIAN 71.2 * H London-Middlesex County Health Link 71.8 * H YORK CENTRAL HOSPITAL 71.1 * H Niagara South East Health Link 71.7 * H Don Valley/Greenwood Health Link** 70.7 * H Salmon River Health Link 70.0 * WILLIAM OSLER HEALTH SYSTEM-ETOBICOKE 70.6 * H NIAGARA HEALTH SYSTEM-WELLAND COUNTY 68.6 * L TORONTO EAST GENERAL HOSPITAL 70.0 * South West York Region Health Link 66.6 * L SCARBOROUGH HOSPITAL (THE)-SCAR.GEN.SITE 70.0 * Rideau Tay Health Link 65.0 * L HUMBER RIVER REGIONAL HOSP-YORK-FINCH 69.9 * PERTH & SMITHS FALLS DISTRICT HOSPITAL 64.1 * L Bramalea Health Link 68.9 * L Niagara South West Health Link 61.6 * L City of Thunder Bay Health Link 68.7 * L Temiskaming Health Link** 55.2 * L North York Central Health Link ** 68.4 * L CORNWALL COMMUNITY HOSPITAL 53.4 * L ST MICHAEL'S HOSPITAL 67.7 * L WEENEEBAYKO GENERAL HOSPITAL 5.8 * L East Mississauga Health Link** 67.6 * L WINDSOR REGIONAL HOSPITAL-METROPOLITAN 67.3 * L North Etobicoke-Malton-West Woodbridge Health Link** 66.2 * L Table 13 Rural HLs and PNs ranked by PC rostering: Full cohort OTTAWA HOSPITAL ( THE )-CIVIC SITE 65.4 * L Std Proportion East Toronto Health Link** 63.7 * L Health Link / PHYSICIAN NETWORK Rostered to PC MOUNT SINAI HOSPITAL 62.7 * L Physician Mid-West Toronto Health Link** 61.9 * L All Ontario cohort 70.0 North Toronto East Health Link 60.7 * L OWEN SOUND SATELLITE NETWORK-SOUTH 87.0 * H ST JOSEPH'S HEALTH CENTRE 59.8 * L STRATFORD GENERAL HOSPITAL 86.2 * H South Toronto Health Link 55.0 * L GEORGIAN BAY 83.6 * H Mid East Toronto Health Link** 54.5 * L GREY BRUCE HEALTH SERVICES-OWEN SOUND 83.4 * H CHILDREN'S HOSPITAL OF EASTERN ONTARIO 49.1 * L Huron-Perth County Health Link** 83.0 * H CENTRE FOR ADDICTION & MENTAL HEALTH-ARF 31.4 * L South Georgian Bay Community Health Link** 82.9 * H HOSPITAL FOR SICK CHILDREN (THE) 30.6 * L Rural Kingston Health Link** 81.9 * H Prescott-Russell Regional Health Link 78.7 * H MUSKOKA ALGONQUIN HEALTHCARE-HUNTSVILLE 78.6 * H Orillia Community Health Link 77.3 * H SUDBURY SATELLITE NETWORK 76.8 * H Peterborough Health Link** 76.6 * H Muskoka Community Health Link 75.2 * H Rural Hastings Health Link** 72.2 * H THUNDER BAY SATELLITE NETWORK-SOUTH 71.8 * H Cochrane South/Timmins Health Link** 68.0 * L South Renfrew Health Link 64.7 * L THUNDER BAY SATELLITE NETWORK-EAST 63.7 * L PEMBROKE REGIONAL HOSPITAL INC 61.9 * L Cochrane North Health Link 61.2 * L TIMMINS SATELLITE NETWORK 56.9 * L THUNDER BAY SATELLITE NETWORK-NW 56.4 * L

Table 14 Urban HLs and PNs ranked by low acuity ED visit rate: Top Table 15 Suburban HLs and PNs ranked by low acuity ED visit rate: 5% Top 5% Std Rate ED Visit: Std Rate ED Visit: Low Health Link / PHYSICIAN NETWORK Health Link / PHYSICIAN NETWORK Low Acuity Acuity (/100,000) (/100,000) Top 5% Cohort Average 39,256 Top 5% Cohort Average 39,256 South West York Region Health Link 23,677 * L HOSPITAL FOR SICK CHILDREN (THE) 13,827 * L Kitchener-Waterloo Health Link 24,684 * L Bramalea Health Link 15,791 * L Cambridge Health Link 26,961 * L SCARBOROUGH HOSPITAL (THE)-GRACE SITE 17,628 * L Guelph Health Link** 31,340 * L HUMBER RIVER REGIONAL HOSP-YORK-FINCH 17,842 * L Brantford, Brant & Six Nations Health Link 32,145 * L North Etobicoke-Malton-West Woodbridge Health Link** 17,893 * L Upper Canada Health Link 32,852 * L WILLIAM OSLER HEALTH CENTRE-BRAMPTON 18,112 * L Niagara South East Health Link 33,316 * L North Toronto East Health Link 18,231 * L Barrie Community Health Link** 35,110 * L Brampton Health Link 18,350 * L SOUTHLAKE REGIONAL HEALTH CENTRE 35,400 * L North York Central Health Link ** 18,659 * L HEADWATERS HEALTH CARE CENTRE-DUFFERIN 36,323 * NORTH YORK GENERAL HOSPITAL 19,346 * L Niagara North West Health Link 36,355 * CREDIT VALLEY HOSPITAL (THE) 19,362 * L South Simcoe and Northern York Health Link** 36,540 * L WILLIAM OSLER HEALTH SYSTEM-ETOBICOKE 19,580 * L NORTHUMBERLAND HILLS HOSPITAL 37,057 * CHILDREN'S HOSPITAL OF EASTERN ONTARIO 20,011 * L Dufferin Health Link** 37,240 * East Mississauga Health Link** 20,514 * L Niagara North East Health Link 39,469 * SUNNYBROOK HEALTH SCIENCES CENTRE 21,047 * L Niagara South West Health Link 41,479 * UNIVERSITY HEALTH NETWORK 21,444 * L COLLINGWOOD GENERAL AND MARINE HOSPITAL 41,969 * YORK CENTRAL HOSPITAL 21,458 * L London-Middlesex County Health Link 45,519 * H HUMBER RIVER REGIONAL HOSP-HUMBER MEM 21,610 * L ST THOMAS-ELGIN GENERAL HOSPITAL 50,673 * H Mid-West Toronto Health Link** 22,301 * L Quinte Health Link** 51,923 * H TRILLIUM HEALTH CENTRE-MISSISSAUGA 22,466 * L PETERBOROUGH REGIONAL HEALTH CENTRE 51,932 * H MARKHAM STOUFFVILLE HOSPITAL 22,716 * L LEAMINGTON DISTRICT MEMORIAL HOSPITAL 52,101 * H SCARBOROUGH HOSPITAL (THE)-SCAR.GEN.SITE 22,884 * L Norfolk Health Link 52,217 * H OTTAWA HOSPITAL ( THE )-GENERAL SITE 22,891 * L NORFOLK GENERAL HOSPITAL 53,387 * H ROUGE VALLEY HEALTH SYSTEM-CENTENARY 22,926 * L PUBLIC GENERAL HOSP SOCIETY OF CHATHAM 55,331 * H Bolton Health Link 22,959 * L QUINTE HEALTHCARE CORPORATION-BELLEVILLE 56,177 * H OTTAWA HOSPITAL ( THE )-CIVIC SITE 24,420 * L NIAGARA HEALTH SYSTEM-WELLAND COUNTY 56,696 * H HALTON HEALTHCARE SERVICES CORP-OAKVILLE 24,430 * L Chatham City Centre Health Link 57,515 * H MOUNT SINAI HOSPITAL 24,740 * L CORNWALL COMMUNITY HOSPITAL 59,569 * H Burlington Health Link 24,742 * L WOODSTOCK GENERAL HOSPITAL 61,401 * H East Toronto Health Link** 24,855 * L Thousand Islands Health Link** 62,885 * H Hamilton East Health Link 25,791 * L BROCKVILLE GENERAL HOSPITAL 63,440 * H GRAND RIVER HOSPITAL CORP-WATERLOO SITE 26,070 * L SAULT AREA HOSPITAL-SAULT STE MARIE 64,146 * H ST JOSEPH'S HEALTH CENTRE 26,448 * L OTTAWA SATELLITE NETWORK 66,343 * H TORONTO EAST GENERAL HOSPITAL 26,540 * L ROSS MEMORIAL HOSPITAL 66,896 * H QUEENSWAY-CARLETON HOSPITAL 26,635 * L Haldimand Health Link 67,055 * H JOSEPH BRANT MEMORIAL HOSPITAL 27,163 * L Kingston Health Link** 68,139 * H CAMBRIDGE MEMORIAL HOSPITAL 27,398 * L Rural Wellington Health Link 72,310 * H ST MICHAEL'S HOSPITAL 28,135 * L North Simcoe Collaborative Heath Link 73,686 * H Don Valley/Greenwood Health Link** 28,332 * L BLUEWATER HEALTH-SARNIA GENERAL SITE 86,440 * H Mid East Toronto Health Link** 29,990 * L ORILLIA SOLDIERS' MEMORIAL HOSPITAL 90,157 * H BRANT COMMUNITY HEALTHCARE SYS-BRANTFORD 29,991 * L Salmon River Health Link 92,621 * H HAMILTON HEALTH SCIENCES CORP-MCMASTER 30,638 * L NORTH BAY GENERAL HOSP-CIVIC/ST JOSEPH'S 102,098 * H WINDSOR REGIONAL HOSPITAL-METROPOLITAN 30,895 * L TIMMINS & DISTRICT GENERAL HOSPITAL 106,046 * H South Toronto Health Link 31,347 * L PERTH & SMITHS FALLS DISTRICT HOSPITAL 107,518 * H Hamilton West Health Link 31,422 * L Rideau Tay Health Link 109,482 * H Arnprior Region and Ottawa West Health Link 32,741 * L Temiskaming Health Link** 160,097 * H NIAGARA HEALTH SYSTEM-GREATER NIAGARA 32,990 * L WEENEEBAYKO GENERAL HOSPITAL 163,462 * H ROUGE VALLEY HEALTH SYSTEM-AJAX SITE 33,041 * L HOPITAL MONTFORT 34,342 * L Hamilton Central Health Link** 35,226 * L Table 16 Rural HLs and PNs ranked by low acuity ED visit rate: Top ST JOSEPH'S HEALTH CARE SYSTEM-HAMILTON 35,375 * L 5% HOPITAL REGIONAL DE SUDBURY-LAURENTIAN 36,265 * L Std Rate ED Visit: Low Health Link / PHYSICIAN NETWORK ROYAL VICTORIA HOSPITAL OF BARRIE (THE) 36,794 * Acuity (/100,000) NIAGARA HEALTH SYSTEM-ST CATHARINES GEN 39,175 * Top 5% Cohort Average 39,256 LAKERIDGE HEALTH CORPORATION-OSHAWA SITE 41,274 * GUELPH GENERAL HOSPITAL 42,965 * H South Georgian Bay Community Health Link** 40,346 * HOTEL-DIEU GRACE HOSPITAL-ST JOSEPH'S 43,819 * H Peterborough Health Link** 44,854 * H LONDON HLTH SCIENCES CTR-UNIVERSITY HOSP 44,334 * H Prescott-Russell Regional Health Link 61,070 * H CENTRE FOR ADDICTION & MENTAL HEALTH-ARF 55,855 * H Rural Hastings Health Link** 62,029 * H City of Thunder Bay Health Link 56,065 * H MUSKOKA ALGONQUIN HEALTHCARE-HUNTSVILLE 63,410 * H THUNDER BAY REGIONAL HLTH SCIENCES CTR 57,861 * H Muskoka Community Health Link 70,276 * H KINGSTON GENERAL HOSPITAL 66,208 * H GEORGIAN BAY 71,462 * H GREY BRUCE HEALTH SERVICES-OWEN SOUND 73,419 * H Huron-Perth County Health Link** 80,191 * H STRATFORD GENERAL HOSPITAL 80,818 * H Rural Kingston Health Link** 82,219 * H Orillia Community Health Link 87,272 * H PEMBROKE REGIONAL HOSPITAL INC 108,678 * H THUNDER BAY SATELLITE NETWORK-NW 110,944 * H South Renfrew Health Link 126,513 * H Cochrane South/Timmins Health Link** 127,562 * H SUDBURY SATELLITE NETWORK 140,802 * H THUNDER BAY SATELLITE NETWORK-SOUTH 149,471 * H OWEN SOUND SATELLITE NETWORK-SOUTH 154,274 * H TIMMINS SATELLITE NETWORK 218,091 * H THUNDER BAY SATELLITE NETWORK-EAST 241,029 * H Cochrane North Health Link 268,008 * H 27

Table 17 Urban HLs and PNs ranked by PC rostering: Top 5% Table 18 Suburban HLs and PNs ranked by PC rostering: Top 5% Std Proportion Std Proportion Health Link / PHYSICIAN NETWORK Rostered to PC Health Link / PHYSICIAN NETWORK Rostered to PC Physician Physician Top 5% Cohort Average 71.9 Top 5% Cohort Average 71.9 JOSEPH BRANT MEMORIAL HOSPITAL 84.5 * H NORFOLK GENERAL HOSPITAL 91.1 * H Burlington Health Link 83.3 * H Norfolk Health Link 90.6 * H HOPITAL MONTFORT 82.2 * H LEAMINGTON DISTRICT MEMORIAL HOSPITAL 88.2 * H HALTON HEALTHCARE SERVICES CORP-OAKVILLE 80.9 * H Haldimand Health Link 88.1 * H KINGSTON GENERAL HOSPITAL 80.8 * H OTTAWA SATELLITE NETWORK 86.1 * H Bolton Health Link 79.7 * H Dufferin Health Link** 85.2 * H ROUGE VALLEY HEALTH SYSTEM-AJAX SITE 79.6 * H Niagara North West Health Link 84.9 * H LAKERIDGE HEALTH CORPORATION-OSHAWA SITE 79.4 * H COLLINGWOOD GENERAL AND MARINE HOSPITAL 84.3 * H WILLIAM OSLER HEALTH CENTRE-BRAMPTON 78.8 * H South Simcoe and Northern York Health Link** 84.2 * H HUMBER RIVER REGIONAL HOSP-HUMBER MEM 78.4 * H HEADWATERS HEALTH CARE CENTRE-DUFFERIN 83.6 * H Brampton Health Link 78.0 * H SOUTHLAKE REGIONAL HEALTH CENTRE 83.2 * H QUEENSWAY-CARLETON HOSPITAL 77.7 * H WOODSTOCK GENERAL HOSPITAL 83.0 * H NIAGARA HEALTH SYSTEM-GREATER NIAGARA 77.6 * H Rural Wellington Health Link 82.8 * H Hamilton West Health Link 77.4 * H Quinte Health Link** 82.1 * H BRANT COMMUNITY HEALTHCARE SYS-BRANTFORD 77.4 * H NORTHUMBERLAND HILLS HOSPITAL 81.7 * H NIAGARA HEALTH SYSTEM-ST CATHARINES GEN 76.9 * H Upper Canada Health Link 80.6 * H Bramalea Health Link 76.7 * H QUINTE HEALTHCARE CORPORATION-BELLEVILLE 80.2 * H CAMBRIDGE MEMORIAL HOSPITAL 76.7 * H Chatham City Centre Health Link 80.0 * H Hamilton East Health Link 76.5 * H Kingston Health Link** 80.0 * H ST JOSEPH'S HEALTH CARE SYSTEM-HAMILTON 76.3 * H PUBLIC GENERAL HOSP SOCIETY OF CHATHAM 79.8 * H ROUGE VALLEY HEALTH SYSTEM-CENTENARY 75.8 * H Cambridge Health Link 78.5 * H HAMILTON HEALTH SCIENCES CORP-MCMASTER 75.2 * H ORILLIA SOLDIERS' MEMORIAL HOSPITAL 77.0 * Arnprior Region and Ottawa West Health Link 75.1 * Brantford, Brant & Six Nations Health Link 76.3 * H MARKHAM STOUFFVILLE HOSPITAL 75.0 * ST THOMAS-ELGIN GENERAL HOSPITAL 76.2 * CREDIT VALLEY HOSPITAL (THE) 74.8 * North Simcoe Collaborative Heath Link 76.2 * SCARBOROUGH HOSPITAL (THE)-GRACE SITE 74.6 * Thousand Islands Health Link** 75.9 * OTTAWA HOSPITAL ( THE )-GENERAL SITE 73.7 * BROCKVILLE GENERAL HOSPITAL 74.9 * UNIVERSITY HEALTH NETWORK 73.3 * Niagara South East Health Link 73.6 * SUNNYBROOK HEALTH SCIENCES CENTRE 73.2 * BLUEWATER HEALTH-SARNIA GENERAL SITE 73.3 * GUELPH GENERAL HOSPITAL 73.1 * Niagara North East Health Link 73.3 * HOTEL-DIEU GRACE HOSPITAL-ST JOSEPH'S 72.7 * SAULT AREA HOSPITAL-SAULT STE MARIE 73.0 * WILLIAM OSLER HEALTH SYSTEM-ETOBICOKE 72.3 * Barrie Community Health Link** 71.7 * ST MICHAEL'S HOSPITAL 72.0 * PETERBOROUGH REGIONAL HEALTH CENTRE 71.4 * TRILLIUM HEALTH CENTRE-MISSISSAUGA 71.6 * Rideau Tay Health Link 70.9 * GRAND RIVER HOSPITAL CORP-WATERLOO SITE 71.5 * NORTH BAY GENERAL HOSP-CIVIC/ST JOSEPH'S 70.4 * YORK CENTRAL HOSPITAL 71.4 * TIMMINS & DISTRICT GENERAL HOSPITAL 70.4 * NORTH YORK GENERAL HOSPITAL 71.3 * Salmon River Health Link 69.7 * North Etobicoke-Malton-West Woodbridge Health Link** 71.0 * ROSS MEMORIAL HOSPITAL 69.4 * ROYAL VICTORIA HOSPITAL OF BARRIE (THE) 71.0 * Kitchener-Waterloo Health Link 69.3 * SCARBOROUGH HOSPITAL (THE)-SCAR.GEN.SITE 70.7 * NIAGARA HEALTH SYSTEM-WELLAND COUNTY 69.1 * East Mississauga Health Link** 70.5 * Guelph Health Link** 67.6 * L North York Central Health Link ** 70.3 * London-Middlesex County Health Link 66.8 * L Hamilton Central Health Link** 69.9 * South West York Region Health Link 66.4 * L TORONTO EAST GENERAL HOSPITAL 69.8 * PERTH & SMITHS FALLS DISTRICT HOSPITAL 66.1 * HUMBER RIVER REGIONAL HOSP-YORK-FINCH 69.7 * Niagara South West Health Link 64.0 * L East Toronto Health Link** 69.1 * Temiskaming Health Link** 59.8 * L LONDON HLTH SCIENCES CTR-UNIVERSITY HOSP 69.1 * L CORNWALL COMMUNITY HOSPITAL 54.1 * L Don Valley/Greenwood Health Link** 68.8 * WEENEEBAYKO GENERAL HOSPITAL 4.3 * L HOPITAL REGIONAL DE SUDBURY-LAURENTIAN 67.3 * L WINDSOR REGIONAL HOSPITAL-METROPOLITAN 66.1 * L MOUNT SINAI HOSPITAL 65.0 * Table 19 Rural HLs and PNs ranked by PC rostering: Top 5% City of Thunder Bay Health Link 63.8 * L Std Proportion THUNDER BAY REGIONAL HLTH SCIENCES CTR 63.7 * L Health Link / PHYSICIAN NETWORK Rostered to PC Mid East Toronto Health Link** 63.1 * L Physician North Toronto East Health Link 61.5 * L Top 5% Cohort Average 71.9 OTTAWA HOSPITAL ( THE )-CIVIC SITE 61.4 * L Huron-Perth County Health Link** 86.4 * H ST JOSEPH'S HEALTH CENTRE 60.9 * L South Georgian Bay Community Health Link** 86.1 * H South Toronto Health Link 59.8 * L OWEN SOUND SATELLITE NETWORK-SOUTH 85.9 * H Mid-West Toronto Health Link** 58.0 * L STRATFORD GENERAL HOSPITAL 85.1 * H CHILDREN'S HOSPITAL OF EASTERN ONTARIO 52.1 * L GREY BRUCE HEALTH SERVICES-OWEN SOUND 84.8 * H HOSPITAL FOR SICK CHILDREN (THE) 37.1 * L GEORGIAN BAY 82.4 * H CENTRE FOR ADDICTION & MENTAL HEALTH-ARF 20.3 * L Rural Kingston Health Link** 82.3 * Prescott-Russell Regional Health Link 79.6 * H Orillia Community Health Link 77.6 * H MUSKOKA ALGONQUIN HEALTHCARE-HUNTSVILLE 77.3 * Muskoka Community Health Link 77.3 * SUDBURY SATELLITE NETWORK 77.0 * THUNDER BAY SATELLITE NETWORK-SOUTH 76.9 * Rural Hastings Health Link** 75.9 * South Renfrew Health Link 71.6 * Cochrane South/Timmins Health Link** 70.0 * Peterborough Health Link** 68.6 * Cochrane North Health Link 65.6 * THUNDER BAY SATELLITE NETWORK-EAST 64.0 * PEMBROKE REGIONAL HOSPITAL INC 62.6 * L TIMMINS SATELLITE NETWORK 58.6 * L THUNDER BAY SATELLITE NETWORK-NW 49.4 * L

Comparison of Overlapping Health Links and Physician Networks

The league tables do not take into account whether a HL or PN located close to each other in the league table are also located in close proximity within the province of Ontario. We sought to examine the extent of overlap between HLs and PNs in terms of the defined patient population. Initial exploration revealed that it is possible for a HL to overlap with all 78 PNs due to the way PNs were created (based on physician referral patterns, not geographical boundaries). We adjusted the overlap criterion to require that at least 5% of the HL’s population overlapped with a PN. This reduced the number of overlapping PNs to between one and six per HL. Information on the PN and HL overlap, including the number of HL individuals overlapping with PNs, can be found in Appendix 8.

We examined two measures of overlap between Health Links and Physician Networks. The first examined the proportion of patients in a defined Health Link that were drawn from the PN with the largest overlap of patients. We found that just under 70% of Health Links patients, on average, were drawn from the PN with the highest degree of overlap. We also examined a more general measure of overlap by considering both the HL and the PN population to determine what proportion of the HL and PN patient population were shared by both the HL and PN, essentially changing the denominator to include both HL and PN populations for the same dyad. In this measure we found an overage of only 46% of patients were common to the HL and PN with the highest degree of overlap. This means that by practice patterns, primary care physicians have many patients who are being treated in hospitals that are not part of the geographically defined health link that they are practicing within. It also means that hospitals are treating many patients whose primary care physician practices outside of the geographic boundary of the health link.

Conclusions This baseline assessment of the performance of Health Links revealed that HLs are starting their integration and coordination efforts at different levels of performance. Some HLs are beginning their process as high performers compared to the provincial average for numerous performance indicators. Other HLs appear to be starting their initiatives with more opportunities for improvement when their baseline performance is compared to the provincial average. These latter HLs are generally those in more rural areas and face challenges resulting from marginalization. Analysis revealed that while urban HLs tended to perform at a higher level when compared to the provincial average, there are urban areas with significantly lower performance levels. This highlights the importance of allowing HLs the flexibility to organize and function in a manner that takes the needs of their population, and available resources, into consideration.

Future evaluations can use the results included in this report as a benchmark to compare individual HLs over time and identify when improvements are occurring as a result of HL best practices. Differences in performance based on rurality and marginalization were not surprising, but highlight important contextual factors for HL leaders and decision makers to consider when deciding how to group HLs with appropriate peer-comparators when attempting to compare performance across HLs. Identifying the specific effect of HL on patient care and outcomes requires being able to identify which individuals are enrolled in HL programs. This was not possible at the time of this report. A registry of patients enrolled in Health Links would enable a direct evaluation of the impact of HL activities on the patients that they have enrolled. A registry that allows for linkage with health administrative data would further enable comparisons of enrolled and similar patients who are not yet enrolled in HLs as this initiative is implemented across the province. The present report describes the general population trends of patients in Health Link geographies but does not evaluate the performance of Health Links specifically in regard to the patients who are enrolled in HL programs. The variation in performance across Health Links suggests considerable potential for improvement by focusing on coordinating and integrating care for individuals in areas of the province with lower levels of performance. While this information is not a surprise, it emphasizes the fact that there are substantial differences in performance between local HLs across and within LHINs.

The results of this report indicate that there are considerable opportunities to improve enrolment with a primary care provider, including among individuals in the top 5% high cost population. The current average proportion of high cost individuals in Ontario who are rostered is 71.9 percent, but this is only 1.9 percent higher than the provincial average for the full population of Ontario. This emphasizes the importance of increasing access to primary care, especially for individuals with complex conditions and who are often frequent users of the health care system. These individuals will benefit from having regular and timely access to a primary care provider.

The finding that rural and suburban HLs had better performance in their top 5% high cost individuals compared to their total population indicates that some HLs may be better at addressing the needs of these individuals. An alternative explanation is that more high cost individuals with more complex health care needs live in urban areas. There were relatively few risk-adjustment factors

included in the indicator standards from the Resource for Indicator Standards (RIS) that we adopted for this report.

Differences in indicator results found when comparing the high cost cohort to the full cohort of Ontarians suggests that demographics beyond age and sex may play a role. As demographics change within a region, so may performance. This means that HLs currently performing well with their current demographic structure need to plan ahead for what care will be needed in the future and/or how care is coordinated. As well, what is currently working well in one HL may not be a model that works for all HLs, unless population and other characteristics are comparable. Even so, the increased focused on integrating and coordinating care for targeted populations in Ontario may lead to further improvements (even spill over effects) for both the cohort of high cost individuals as well as Ontario’s full population.

Measures of marginalization further emphasize the need to address issues such as lack of housing, low levels of education, unemployment (or under employment), and the importance of social supports. Health Link leaders recognize this and know that the health care system cannot solve all problems that lead to poor health outcomes and high usage of health care services. Some HLs have begun to include organizations that provide social assistance in their discussions on how to integrate and coordinate care, and other services, for their targeted population. This early work can lead to structures that may be useful at the broader population level to address poor health outcomes and other issues that increase marginalization scores.

The higher proportion of HLs that are suburban and rural compared to the higher proportion of urban PNs indicates that voluntary HLs have formed more rapidly in suburban and rural areas compared to urban areas. This may be partially due to the ease of identifying the appropriate network of providers and that stronger existing relationships exist among different kinds of providers in suburban and rural areas. It may be more difficult to foster relationships within urban areas, particularly where existing practice and referral patterns (in PNs) are less clearly defined. This is also highlighted in Appendix 8 where the degree of overlap between HLs and PNs is much higher in suburban and rural areas compared to urban areas.

The HLs initiative is focused not only on controlling health care costs, but also on improving health care provided at the individual level. These are two important and related areas that can improve as HLs continue working on increasing the integration and coordination of health care services, and even other social services. As HLs continue to spread across Ontario they should keep in mind that population level improvements can also lead to improvements in costs and care provision. There are currently no indicators being used to track the performance or success of HLs on population level measures. This highlights the usefulness of the Triple Aim framework as a means to guide quality improvement efforts. Future research and assessments should take other population level health care indicators (e.g., cancer screening, diabetes care) and even population health indicators (e.g. physical activity) into account. This will help decision makers determine priority areas for networks to improve care and the extent to which HLs need to expand their focus to include targeting more upstream interventions. Population level or ‘upstream health care’ interventions can have significant effects, but may be more challenging to tie to a

specific HL initiative because positive effects can take many years before they are measurable and may be influenced by other policies.

Achieving effective inter-organizational integration across the care continuum is a challenging but important goal for Ontario’s health care system. The example of Accountable Care Organizations in the US indicates that it will take time for success to be achieved. HLs have sought to build productive relationships among health care provider partners, and increasing integrated care in a way that focuses on the needs of individuals receiving health care services (see the second report in this series). As HLs continue to develop, increase coordination of care, share best practices, and focus on the needs of their respective populations it is expected that their performance on the indicators used to measure their success will show improvements over time. Knowing which providers to engage and better approaches to identifying which patients to target for HL interventions will be a key factor in the success of HLs.

The model of Accountable Care Organizations described in the first report of this series could be pursued in Ontario based either on geographic boundaries, or enrolment models following existing practice patterns; it will be highly challenging to enable accountability and provide equitable funding with a hybrid approach. Differences in existing patterns of care for patients among providers (Physician Networks) compared to the geographic approach employed by Health Links definitions will have to be resolved in order for HLs to effectively manage care for complex patients. Full population-based accountability will require either that patients be willing to change primary care providers or that Health Links be reorganized to engage with providers in their referral network regardless of geography.

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Institute for Health Care Improvement (2014). Website. Available from: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

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Ministry of Health and Long-Term Care (2014) Resource for Indicator Standards. Available from: http://www.health.gov.on.ca/en/pro/programs/ris/alpha_indicators.aspx. Accessed on July 15, 2014.

Stukel, TA; Glazier, RH, Schultz, SE; Guan, J; Zagorski, BM; Gozdyra, P; and Henry, DA (2013) Multispecialty physician networks in Ontario. Open Medicine, 7(2): e40.

Wodchis, WP; Hirdes, JP; Feeny, DH. (2003) Health-Related Quality of Life Measure Based on the Minimum Data Set. International Journal of Technology Assessment in Health Care, 19(3): 490- 506.

Appendices Appendix 1 – HSPRN Indicators used for assessing HLs

Appendix 2 – Baseline demographic information for LHINs and HLs

Appendix 3 –Baseline HL performance of early and later adopters, both cohorts: 22 indicators

Appendix 4 –Baseline HL performance by rurality, both cohorts: 22 indicators

Appendix 5 – Total Zscore comparison of HL performance in both cohorts by rurality: 22 indicators

Appendix 6 –Baseline HL performance by marginalization quintile, both cohorts: 22 indicators

Appendix 7 – League tables for HL and PN for 6 selected indicators by rurality: Both cohorts

Appendix 8 – Overlap of individual Ontarians between HLs and PNs